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Dr. Bruce Fisher
Department of Medicine, Division of General Internal Medicine
Produced by the Academic Technology Group
CLINICAL TEACHING
AND LEARNING 101
INTRODUCTION
1
CLINICAL TEACHING AND LEARNING 101
Welcome to Clinical Teaching and Learning 101. This module will
introduce you to clinical teaching and learning, and provide you with
some tools to help you teach effectively.
This course is both for those who are just starting their role as a clinical
teacher, and for more experienced clinical teachers who wish to discover
new strategies to improve their teaching.
This module will cover the following topics:
What is different about clinical teaching and learning?
How will you benefit from teaching?
What strategies can you use to teach effectively?
UNDERSTANDING CLINICAL TEACHING
2
vignette THINKING ABOUT THE CLINICAL TEACHING ENVIRONMENT
The clinical teaching environment presents a number of opportunities and challenges
which are not found in the classroom. In the next slides, you will be presented with a
typical clinical teaching encounter. A small team, consisting of a preceptor, a junior
resident and two medical students, review a patient at the beginning of the academic
year.
The vignette:
It is 9:30 am in the emergency department. A 60 year-old man with small cell lung
carcinoma has been sent to the hospital emergency department by palliative home care
owing to decreasing LOC and weakness.
The patient’s condition is stable but he has a low serum sodium level of 124 mmol/L.
As you read through the dialogue on the next slide, consider the interaction and the
environment in which it takes place.
vignettePreceptor: So what are the possible causes of a low sodium? Anyone, anyone?
Student 1: Decreased intake?
Preceptor: Actually, no. Not deceased intake per se… (silence)
Preceptor: Anyone…causes of hyponatremia?
Student 2: How about increased intake of water?
Junior resident: Hypothyroidism…
Preceptor: Yes. Any other endocrine causes?
(silence)
Preceptor: Okay, how about Addison’s disease?
Junior resident: Addison’s disease? I think that can do it…
Student 1: Yes, and diabetes insipidus.
Junior resident: No, diabetes insipidus causes high sodium.
(silence)
Student 2: What about beer potomania?
And so on…..
WHAT DO YOU THINK?
How appropriate is this interaction for the clinical teaching environment?
Explain your answer.
Then read on
One who studies medicine without books sails an uncharted sea, but one
who studies medicine without patients does not go to sea at all.”
— W. Osler
WHAT THE CLINCAL TEACHING ENVIRONMENT PROVIDES THE LEARNER
The clinical teaching environment provides unique opportunities to
demonstrate, observe, and assess the performance of skills and knowledge.
Specifically, the clinic offers learners:
an opportunity to apply knowledge, skills, and behaviors in authentic
settings to authentic context-specific problems.
an opportunity to develop clinical reasoning and decision making skills.
an explicit approach to the uncertainty associated with clinical decision
making
“real-time” integration of key CanMEDS roles such as “communicator” and
“collaborator” into their educational experience
“Do not waste the hours of
daylight listening to that which
you may read at night.”
— W. Osler
DIFFERENT PLACES, DIFFERENT APPROACHES
Classroom teaching Clinical teaching
What is being asked “What do you know?” “How do you apply it?”
What the learner demonstrates Demonstrate knowledge and skills Problem solve in particular contexts
What competence is assessed Comprehensiveness and accuracy of
knowledge and skills
Selective and context appropriate
application of knowledge and skills
The primary method of teaching Working from general principles to
some examples
Working from specific examples to
general principles
Method and site of learning Home work and white boards Bedside practice
Compared to the average classroom, the clinic is a labile and fast-paced
environment. As a result, there are differences between the kinds of teaching
and learning that take place in the classroom and the clinic.
Below is a summary of some of the key differences.
PREPARING TO SUCCEED
3
WHY SHOULD YOU TEACH?
Take a minute to think about your past experience with teaching and
learning in the clinical environment, and consider why it could be
beneficial for you to engage in clinical teaching.
What can you expect to give and to gain from teaching?
Jot down your thoughts below and then continue.
More reading about this: Weinholtz, D., Edwards, J. C., & Mumford, L. M. (1992). Teaching during
rounds: A handbook for attending physicians and residents. Baltimore: Johns Hopkins University
Press.
WHY CLINICIANS SHOULD TEACH
There are a number of good reasons why clinicians should be involved in
clinical teaching. Here are just a few:
Teaching is a core competency (CanMEDS Scholar role).
Teaching others is a great test of your clinical skill and reasoning, and a deep
form of learning. As Aristotle famously said, “teaching is the highest form of
learning.”
Teaching is fun and deeply rewarding.
IDENTIFY THE CHALLENGES
Regardless of your experience, teaching in the clinical environment presents
numerous challenges. The clinical environment is labile, unpredictable, and time
constrained. Because it involves patient care responsibility it requires immediacy of
action and a need to simultaneously meet (and balance) teaching and clinical
objectives. Learners often have multi-level, multi-disciplinary learning needs, and
delegation of responsibility can be complex.
However, as you consider becoming engaged in clinical teaching, you may feel nervous
about whether you are up to the task. After all, teaching adds a whole new level of
challenge and responsibility to an already challenging job.
Think about any such concerns that you might have about your ability to teach, and
then proceed.
“When I first started teaching, I found it
overwhelming. I felt I had to teach
everything at the same time.
Eventually, I learned to look for small
moments that provided an opportunity
to improve on a key skill..”
COMMON CONCERNS ABOUT TEACHING
“I’m not an Expert”
Some clinicians who are new to clinical teaching feel they are unqualified to
teach because they are not experts in the field being taught and “do not know
enough to teach”. Additionally we all dislike making mistakes, especially in
front of an audience.
Of course it is important to possess up-to-date and valid clinical knowledge and
skills if we wish to teach them. However, beyond the need for a basic mastery
in a subject area, literature from multiple specialties consistently fails to rank
medical expertise as a critical prerequisite for effective teaching. In fact it
appears that “experts” need to deconstruct their skills to a mastery level to most
effectively teach them.
Teaching will take too much time
Actually, there are a number of very effective teaching strategies that don’t take
much time, which you will learn about later in this module.
Students can’t take feedback
It is possible give feedback and still be on speaking terms afterwards. Later in
this module, you will be introduced to some ways that you can effectively
communicate feedback to learners.
THE FOLLOWING ARE REQUIREMENTS TO BECOME A GOOD
CLINICAL TEACHER:
Up-to-date clinical knowledge and skills. As a clinical teacher, you must be able
to competently demonstrate, explain and assess key clinical
competencies.
An understanding of the nature and purpose of clinical teaching. Clinical teaching
requires an appreciation for the challenges and opportunities of the
clinical environment, as well as the needs and abilities of adult learners.
A flexible and observant approach. Rather than trying to teach everything,
good clinical teachers seize upon teachable moments as they present
themselves.
An effective “toolkit” of teaching skills and strategies. In the remainder of this
module, you will be introduced to a set of strategies that you can use to
ensure that your teaching is effective.
THERE ARE TOOLS TO HELP
Clinical teaching is challenging, but the good news is there are some useful tools to
make your job easier. In this presentation, we’ll cover a general approach ( the RES
STAR Approach to Clinical Teaching) and three very useful teaching tools:
One Minute Preceptor
Active Observation
Effective Questioning
Using this approach and basic tools every day will help you be an effective clinical
teacher.
FRAMING CLINICAL TEACHING
4
FRAMING CLINICAL TEACHING: THE RES STAR APPROACH
The Royal College of Physicians and Surgeons of Canada has developed a
framework that can be used to guide you in performing the necessary
tasks of clinical teaching. The components parts which can be broken
into two phases, can be remember with the acronym RES STAR.
RES
Do this when you establish a new relationship with a learner:
1. Recognize – recognize the learner, they learning style and needs.
2. Expectations – determine and agree on expectations.
3. Situate – help situate the learner in the environment and their role.
STAR
Do this whenever you teach:
1. Set up the educational encounter.
2. Teach or observe.
3. Assess and give feedback.
4. Role model and reflect on teaching.
RES
RECOGNIZE THE LEARNER
Start by recognizing the learner and understanding their:
Name
Background
Program
Level of training, experience, and needs
Recognizing the learner will help you and the learner make a teaching
“contract”. This contract is the mutually agreed upon method by which
both learner and teacher will determine and produce the “best fit” of the
learner’s knowledge skills and learning goals and learning style, to the
teacher’s educational goals teaching methods and clinical context in
which this will take place. Taking the time to make this step explicit to
your learners will increase the usefulness and efficiency of your teaching
and learning relationship.
More about teaching contracts later!
RES
EXPECTATIONS
Both learners and teachers should determine shared expectations to
form an agreement on key points that outline how you will work together.
This agreement will form your learning contract.
What do you consider achievable goals and expectations?
How and when you will work together ?
What can be taught, learned, and assessed?
What areas will be focused on — what are the learner’s educational
needs?
How will you focus on these needs — what specific strategies will you
employ?
What degree of competence is expected?
How and when assessment be done?
How and when feedback will be given?
RES
vignette WHAT DO YOU EXPECT?
Read this dialog between a clinical preceptor and a new medical student who are on
call together.What elements of an educational contract do you recognize? What might be
missing? Use the tips on the preceding slides to help answer.
Preceptor: Hi. So it looks like we are on together today. I see you have your beeper
and phone, and this is your second rotation this year. Do you know where everything
is?
Student: Yes, thanks. The group orientation was pretty good. This the first time I
have been on call though.
Preceptor: Well there is already one patient down in emergency that needs
admission. Maybe I could just go over a few things before you start.
As you know, I or the senior resident will be asked to see people from emergency and
depending on how sick they are we’ll be calling you earlier or later on for you to see.
One of us will go over each case with you when you are finished your history and
physical, and have had a chance to make a summary.
vignettePreeptor: Obviously if you have concerns or things change with regards to the
patient status you can call any time but otherwise we’d like you to try and make a
problem list and sketch out ideas about management before we review the case.
We will focus on what you think is going on and why you think so, so when
presenting give the “bottom line at the top”.
Don’t worry — we will assess your database and reasoning as to why you think so.
We hope that you can perform your history and clinical exam in 45 minutes or so do
you think you could do that?
Student: I think so. I will certainly call you if I am uncertain or have questions, or
things change.
Also, if there aren’t any patients needing admission, and the ward is quiet, could I
just accompany you if you see consults that don’t need admitting?
Preceptor: That sounds practical. So why don’t you go down stairs now and see that
patient- (Mr. X): she is in Z pod.
Student: Okay.
CAN YOU SEE THE EDUCATIONAL CONTRACT?
What elements of an educational contract do you recognize?
Consider what elements might be missing. Then proceed.
SITUATE
New learners need you to introduce them into the unfamiliar and often
complex learning environment of clinical care.
The first step in teaching is situating the learner to the environment in
which they will be learning, and helping them understand their role.
For example
Introduce the learner to the setting in which they will be learning [by
doing X].
Help the learner understand their role within the setting [by doing X].
Explain the patient flow and work to be done [by doing X].
RES
SETTING UP THE ENCOUNTER
Choose an appropriate setting to teach. This may require flexibility and
opportunism to identify potential “teaching moments”.
Make sure that you and the learner and know and agree on:
What will be focused on (the task)
How focus will be achieved (by outlining the scope, content, context, and
priorities).
The degree of competence or completion that will be expected.
For example: “This next patient has dyspnea. They seem stable. You
mentioned you wanted to practice your approach to this problem. After I
introduce you why don’t you take a directed history and physical
examination to try to determine the cause, and we can review it in 30
minutes. When I come back, I will be asking you what you think is going
on and to explain your reasoning as to why you think so, in the presence
of the patient, and then we can review any pertinent physical findings.
In the interim, call me if you are concerned or the patient’s status
deteriorates. Is that OK with you? Do you have any concerns or
questions?”
STAR
TEACH OR OBSERVE
When to teach?
Be flexible – choose an appropriate time to engage the learner.
Seek the teachable moment – and tailor teaching to your situation . For example, although you
had planned to observe your learner doing the knee examination, the patient is tired and worried. It
may be a better time to demonstrate or observe another CanMEDs role such as communication or
advocacy. Remember that one of your most important roles is major roles is to choose what is best
to focus on.
How to teach?
Demonstrate
Observe
Ask questions (at an appropriate level)
What to teach?
Knowledge, skills, and attitudes
All CanMEDS Roles
Tailor to the learner’s level and learning needs
Tailor to the context
Whenever possible focus on the “Do” of Miller’s pyramid
STAR
Does
Shows how
Knows how
Miller’s pyramid
ASSESS AND GIVE FEEDBACK
Reinforce what was done well to consolidate good performance
Identify what was not done well and discuss the means to improve performance
Provide direction -“where to go next”
Remember: supervise and keep everyone safe
STAR
THE TEACHING-LEARNING EVENT
Focus on task
Teach or Observe
Assess
Feedback and linked teaching
Linked teaching
Plans for improvement
How and when to do assess if it is working
How and when to discuss if it’s workingSpecific & appropriate strategies
Situate and setup
Do
Show
Know
Teaching pointsCommit to improve performance
Appropriate to clinical context
ROLE MODEL AND REFLECTION
Although you may not always be aware of it, you are always modeling
roles — and modeling has a profound effect on the consolidation or
change in performance, attitudes and behaviors in others.
In our own clinical behaviors we demonstrate:
Professionalism
Intellectual honesty
Approach to uncertainty
Reflection on clinical performance and teaching
Continuous improvement and deliberate practice
“How did that go?”
“What could be better?”
STAR
TOOLS YOU CAN USE
5
WHAT METHOD WOULD YOU USE?
A student is on call with you.
She pages you to say she is finished doing the history and physical of a patient who is
being admitted, and is “ready to discuss the case” with you.
Otherwise, all is quiet and you are available.
What teaching method would you use to proceed?
Think of educational principles to explain the appropriateness of your choice.
ONE MINUTE PRECEPTOR
The One Minute Preceptor is a “micro-skills” teaching framework that is
useful when working with learners who have some reporter and
interpreter skills. First introduced as the “Five-Step `Microskills' Model of
Clinical Teaching” (Neher, Gordon, Meyer, & Stevens, 1992), the
approach has become a widely established way of framing teaching
moments in clinical settings.
The One Minute Preceptor can help you to:
Elicit critical thinking from learners about the case, rather than a
factual summary.
Gain greater insight into a learner’s clinical reasoning.
Prompt and structure your feedback on the learner’s performance.
On the next slide, you’ll be presented with a modified version of the
framework.
Skill Learner activity Preceptor action Rationale
Get commitment Performs clinical skill
and awaits guidance
Observation Promotes higher order
thinking in learner and
more useful assessment
and feedback in teacher
Probe for
understanding
Links commitment to
underlying data,
reasoning and evidence
Assesses learner’s use
of data, key features
and reasoning to
formulate problems and
decisions
Promotes development of
independent clinical
reasoning skills
Teach general rules What can be or was
learned from the
encounter
Key features, pearls
and pitfalls of specific
clinical encounter,
targeted to level of
understanding
Instruction more
memorable and useful
when attached to clinical
context by general rule or
guiding principle
Provide Consolidative
feedback
Self-appraisal identifies
success
Comment on specifics
of the success and what
effect it has
Explicit reinforcement
consolidates and improves
nascent skills
Provide Constructive
feedback
Self-appraisal for
omissions distortions or
misunderstandings
Thereafter ASAP
discuss how to avoid or
correct in future
Unattended mistakes
recur
ONE MINUTE PRECEPTOR (MODIFIED)
Adapted from: Neher JO, Gordon KC, Meyer B, Stevens N. A five-step microskills model of clinical teaching. J Am Board Fam Prac. 1992;5:419-24
SCENARIO B
Later that evening, another patient arrives who is stable but is much more
complicated. You wonder if the case may be “over the head” of the medical student
who is working with you.
The student reminds you that they had asked to accompany you and would really like
to be involved in seeing the case.
What teaching method you would use to proceed?
Think of reasons for your choice, and then see the next slide.
ACTIVE OBSERVATION
Active observation is a good introductory strategy for novice learners,
when the complexities and required skills of the patient assessment are
still too sophisticated for the learner.
During active observation, the learner sees the patient with the preceptor
and is asked to observe the preceptor perform a clinical skill, which
might include communication, history taking, physical examination, or
other procedures.
Active observation allows the learner to see patients and observe overall
approaches and cadences of clinical interaction, despite having limited
clinical knowledge or skills.
Surveys of learners have shown that active observation learning
experiences are very highly rated.
KEEPING IT ACTIVE: AN EXAMPLE
You can prevent active observation from turning into passive
“shadowing” by taking the following steps:
Describe the rationale for the observation, e.g. “Proper assessment of
motor power is important in the examination for an upper motor neuron
lesion.”
If not already in the room introduce the learner to the patient.
Declare exactly what should be observed, e.g “Watch how I examine the
motor power, especially comparing sides and flexor and extensor groups.”
Allow the learner opportunity to practice, e.g. “On the next patient, I
want you to examine for the presence of an upper motor neuron lesion,
with special attention to motor power.”
ASKING QUESTIONS
6
ASKING QUESTIONS
Asking questions is an important way of determining your learners’ level of
knowledge and skill. Without asking, you can only infer knowledge and skills
in others.
Asking questions also helps shift the focus for learners from thinking about
facts (who and what) to reasoning and problem-solving (why and how).
Different types of questions have different uses. You should choose your
questioning method based on what learning it is that you wish to promote.
Examples of the most common types of question are found on the next slide.
QUESTIONING
Type Use Example Pro Con
Convergent Determining basic knowledge or level
List three causes of congestive heart failure.
Predictable Teacher talks
Divergent Stimulates:
InteractionDiscussion New approaches
Your colleague is uncertain whetherthe patient has congestive heart failure. What do you think?
Others engagedRedirects
Unpredictable
Probing Explores reasoning Can you explain why you think congestive heart failure is the most likely diagnosis?
Clarifies, validates
Explores HOTS
IntrusiveChallengingCritical
GIVING FEEDBACK
7
FEEDBACK
Feedback is a critical component of the teaching-learning cycle, and for
that matter deliberate practice. Without knowing outcomes of our
performance it is not possible to continue what is successful and stop or
correct what is not.
When done well, giving feedback provides external scaffolding to
promote and guide the individual’s process of self reflection.
vignette GIVING FEEDBACK ON-CALL
It is evening on-call in the emergency department. A very flustered and obviously
busy senior resident comes down to review the case with you and the student.
The senior asks the medical student to provide a summary of this patient who has a
septic arthritis of the right knee.
At this point the senior briefly asks some questions of the patient and examines the
knee and then you all step outside of the room.
vignette Senior: “I‘d just like to give you a little feedback on your summary.”
Student: “Okay.”
Senior : “Your summary was alright, but I am a bit concerned about your reasoning skills…”
Student: Appears a bit taken aback.
Senior :“…you left out the fact that the person has obvious underlying rheumatoid arthritis,
and you didn’t link the story with your conclusions very well.”
“For example, you didn’t mention any details about the results of the aspiration they did
when the patient arrived.”
Senior: “Making summaries is useful for developing clinical reasoning skills. Also, you didn’t
mentioned anything about management although in retrospect given your summary we
would have to discuss it differently anyway.”
“It’s important for you to learn to take ownership of patients, and part of that is making a
diagnosis and reasonably detailed management plan. I know it’s a lot of work but if you
aren’t interested in doing that, then it really limits what we can do together. Okay?”
Student (quietly): “Okay”
Senior: “Well, anyway, I suggest we move on, as there a two new people the emergency doc
has asked us to see. Look, generally you are doing very well, but you really need to work on
your summary skills. Okay?”
Student: “Alright.”
WHAT DO YOU THINK?
How would you rate the quality of this feedback: good, satisfactory, unsatisfactory?
What could be improved? If you think it could be improved, how would you have done
it differently?
TWO TYPES OF FEEDBACK
Broadly speaking, there are two types of feedback: summative and
formative.
Summative feedback
E.g. Your dinner guests compliment you on the soup you made.
A summary judgment of performance.
What most people think of as feedback.
Formative feedback
E.g. Before your dinner guests arrive, you ask your spouse to taste your
soup and tell you if there is enough seasoning.
Provides interim information to improve or consolidate performance.
An essential component of teaching.
HOW TO GIVE FEEDBACK
Feedback can inform the learner to start stop, continue, or change
behavior. If done well all feedback is “positive”; only varying in
whether it is consolidative or constructive.
Be objective and accurate. Base your feedback on observed behaviors
rather than inferred beliefs or values.
Do: “You did not allow time for the patient to ask questions at the
end of the interview.”
Don’t: You did not seem interested in what the patient thought
about your treatment plan.”
Be pertinent, consolidating, and constructive
Focus feedback on mutually agreed upon objectives and goals.
Consolidative feedback plays an important role in letting your learners
know what they are doing well (continue), or have mastered a task. It is
not only edifying-it frees the learner to concentrate on any other areas in
need of improvement.
Keep it short and to the point
Keep observation periods short to allow for focused feedback.
Smaller units of feedback, spread out over time are more valued than
big infrequent chunks.
Give feedback that is actionable
Constructive feedback should be specific and limited in amount, and
focused on issues the person can control, with clear and useful
instructions for improvement that are linked to enabling support.
Giving too much information at a time may overwhelm the listener,
who may then either disregard everything, or pull out the points that
confirm their own impressions, rather than the ones you believe are
most important and pertinent.
How to give feedback
Feedback should be ongoing and frequent.
The most common complaint about feedback is its absence. “If only
someone had told me how I was doing!”
Regular feedback creates an expectation of feedback which enhances
receptivity and positive response in learning behaviors.
Unexpected feedback, especially if it is not objective or actionable, is
likely to produce a negative emotional response.
Feedback should be as immediate as possible — especially after a
critical incident has taken place.
When should you wait to give feedback?
If appropriate, allow learners to complete their performance before
delivering feedback.
In an emergency or potentially embarrassing situation, postpone
feedback for a suitable time.
How to give feedback
A SCRIPT FOR GIVING FEEDBACK
1. Listen to self-evaluation first.
If necessary, ask the learner to be specific, and balanced, outlining both what they thought went well and what did
not. This serves to inform you of the learner’s perception of their performance, and also promotes increasing their
skill and judgment in self assessment.
2. Use this self evaluation to customize your feedback.
Depending on the quality of the self-evaluation you may have much or little to do. Learners inexperienced in self
assessment often generalize or polarize assessment of their performance, and may require considerable “scaffolding”
with your feedback. With an experienced adult learner with good self evaluation skills, aside from agreeing with their
assessment, your main task may be to help them link the assessment to action plans!
3. Discuss and validate what was done right and should be continued.
4. Discuss what needs starting, stopping or improving.
5. Decide what to do next time.
There should always be a recognizable action outcome to the feedback given, be it continuance, starting, stopping, or
changing of behaviors.
6. Provide clear and useful instructions and support for improvement
“This is where “teaching pearls or general rules” are often discussed.
7. Summarize feedback and plan
Whenever possible, this should be the learner’s task. Communication is generally more difficult and less effective
than we think it is! This is the means to ensure you both share the same understanding about the feedback and
plans.
“We are what we repeatedly do.
Excellence, then, is not an act
but a habit.”
— Aristotle (384-322 BC)
SUMMARY
8
IN SUMMARY
Clinical teaching has unique opportunities and challenges and there are
many reasons for you to become involved in clinical teaching. Although
clinical teaching can be challenging, there a number of ways you can
prepare yourself.
Frame teaching encounters with the “RES STAR” approach.
In addition, there are some effective tools that you can use everyday:
The One Minute Preceptor
Active Observation
Effective Questioning
Effective Feedback
So go out and use these techniques to improve the effectiveness and
enjoyment of your teaching!
ONE MINUTE PRECEPTOR (ORIGINAL)
5. Teach a general principle
Find a teaching point that can be applied to other situations.
4. Give guidance about errors and omissions
Tell the learner what areas need improvement.
3. Reinforce what was done well
Tell the learner what they have done well.
2. Probe for supporting evidence
Explore the basis for their answer.
1. Get a commitment
Ask the learner to verbally commit to an aspect of the case.
Adapted from: Neher JO, Gordon KC, Meyer B, Stevens N. A five-step microskills model of clinical teaching. J Am Board Fam Prac. 1992;5:419-24
CREDITS
Author
Dr. Bruce W. Fisher
Department of Medicine, Division of General Internal Medicine
Acknowledgements
[See references]
Produced by the Academic Technology Group
Copyright
© 2014, Faculty of Medicine & Dentistry, University of Alberta